Lesson Learned Statement:A HEPA filter bank at the Plutonium Finishing Plant was found in service following installation of new filters before the filter bank had been leak tested and declared operable by the Surveillance Shift Manager (SSM). Imprecise and incomplete communication between the Person-in-Charge (PIC) and the SSM did not allow the SSM to clearly recognize that the filter dampers were open. A Technical Safety Requirement (TSR) was violated because the SSM did not know existing plant conditions.
Discussion:On Friday, November 14, 2003, a HEPA filter bank in Filter Box (F-16) at the Plutonium Finishing Plant was replaced. Filter replacement and leak testing is normally completed in a single shift. However, because the work could not start until after lunch, HEPA filter replacement was performed during day shift and leak testing was turned over to swing shift.
At the end of day shift, the F-16 filter dampers were opened in accordance with the work package but without knowledge of the Day Shift SSM who therefore turned over the wrong configuration (dampers closed) to the Night Shift SSM. The Night Shift SSM discovered the filters were in service while hanging Caution Tags on the dampers to prevent personnel from placing F-16 in service until completion of testing.
Analysis:A TSR stipulates that the PFP may place filters in service temporarily under administrative control for testing. That administrative control TSR was violated because the SSM was not aware that the filter bank was in service and therefore could not maintain administrative control.
The work package did not clearly alert personnel when the LCO Required Actions were entered or exited. A change was made to the work package to add an administrative control. The step affected the facility Safety Basis but was not placed in the correct sequence. Therefore, LCO Required Actions were not in the proper sequence with the work steps. This change was reviewed by the SSM, the PIC, and the Design Authority. Although the intent of the added step was to allow the SSM to determine when LCO Required Actions had been satisfied, the step was not written so that it would convey that intent to a potential Safety Basis reviewer. This change should have been reviewed by the appropriate designated reviewers per HNF-RD-8635 "Review of Technical Documents".
The change to the work package was not included in the copy of the work package used by field personnel. Therefore, they did not notify the PIC of completion of that step and the SSM was not notified of the damper position in a timely manner. The delay in notifying the SSM led to confusion later in the shift during discussions about damper configuration.
Communication between the Day PIC and the Day SSM was less than adequate for the Day SSM to understand the status of work or the damper configuration. Had the turn over included a review of the work package, the SSM should have been able to understand the actual configuration relative to the LCOs at the end of the shift.
An Unreviewed Safety Question (USQ) Screening concluded that, when complied with, the established Safety Basis controls are adequate to ensure the safety of operations. On 12/8/03 the work package was closed with the ventilation system restored to service compliant with TSRs.
In this event, field personnel did not recognize that the SSM needed to know that the dampers were open at the end of shift and that this configuration was under a TSR requiring the SSM to maintain administrative control over the damper configuration.
Recommended Actions:PICs must review work packages when turning over TSR related work.
Work package planners and reviewers must ensure that work steps are in the proper sequence and are adequate for personnel to recognize the points of entry into and exit from LCO Required Actions.
Originator:Fluor Hanford, Inc.
Submitted by John Lukes (509) 373-3104
Contact:Project Hanford Lessons Learned Coordinator; (509) 373-7664
Name Of Authorized Derivative Classifier:Not required
Name Of Reviewing Official:John Bickford
Priority Descriptor:Blue / Information
Keywords:Conduct of Operations, Criticality, Job Planning, Mechanical/Structural Systems - Ventilation System/Fan
References:Occurrence Report RL--PHMC-PFP-2003-0035
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DOE Function / Work Categories:Authorization Basis
Conduct of Operations - Configuration Management
Conduct of Operations - Procedure Development
Conduct of Operations - Work Control
Conduct of Operations - Work Planning
Operations - Facility
ISM Category:Define Work
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